1. Has your heart got the guts?
dr tom mabin
franschoek

5. Global Mortality 2000: Impact of Health Risk Factors
High BP
Tobacco
High cholesterol
Underweight
Unsafe sex
High BMI
Physical inactivity
Developing region
Developed region
This slide highlights the contribution of some of the leading health risk factors to global mortality, e.g. high BP, tobacco use, high cholesterol, and under-nutrition.
In both developed and developing regions, high BP was among the major causes of disease burden and a leading cause of global mortality.
Intensive strategies to target leading global health risk factors such as hypertension are therefore necessary.
Reference
Ezzati M, et al. Selected major risk factors and global and regional burden of disease. Lancet 2002;360:1347–60.
Alcohol 1 2 3 4 5 6 7 8
Attributable mortality in millions (total: 55,861,000)
Ezzati et al. Lancet 2002;360:1347–60

6. Rate of obesity rising:57% Increase diabetes mellitus 40%
Europe:
Rate of obesity rising:57%
Increase diabetes mellitus 40%
Smoking constant:18%
Physical activity constant:
45% BP above target
Lipid levels 33% above target (prev 55%)

7. Proven Mortality Benefits In Lowering LDL
A 28 % Reduction in LDL-C significantly reduces cardiovascular events
Major corronary events
Coronary deaths
Cardiovascular deaths
All-cause deaths
Per cent proportional risk reduction
-31 %
-29 %
-27 %
-21 %
-35
-30
-25
-20
-15
-10 -5
LaRosa et al, JAMA 1999; 282:

8. The endothelium…miles and miles of “silk stocking”……………

9. How atherosclerosis develops
Cholesterol penetrates inflammed artery to form plaque
Platelets stick to plaque

10. Plaque rupture STEMI NON-STEMI Without occlusion With occlusion
ACS describes the clinical manifestations of disruption of cornary arterial plaque complicated by intraluminal thrombosis and distal embolisation.
Distal embolisation results in a small troponin rise, which can predict serious proximal “hot” plaque/stenosis.
Without occlusion
With occlusion
STEMI
NON-STEMI

11. Balloons and stents Highly successful Beneficial in short term
Can recur
Disease continues
Not treating the underlying problem…
Major questions remain………..

12. High cholesterol high blood pressure smoker diabetic
The paradox………
High cholesterol high blood pressure smoker diabetic

13. The paradox…..
Medium cholesterol
Normal BP
Not diabetic
Etc
etc

14. The paradox puzzle

15. “I would lie for you…and that’s the truth” Meatloaf… 1995

16. 1980’s >500,000 patients with DU Most required surgery
Helicobacter pylori bacteria implicated
Cured with antibiotic
No more surgery!!
DNA footprint and new genetic technology can identify many more bacteria

17. Gut Microbiotica >135,000 species of bacteria
Plus fungi,protoplasms
Assist indigestible food
Protect gut lining but can be
triggered to cause inflammation
Inflammed gut lining leaks bacterial metabolites which spread to various
body organs eg arteries.

18. Plaque and gut bacteria
DNA and genetic analysis of specific gut bacteria and plaque show similar metabolites
A metabolite strongly related to atheromatous plaque is trimethylamine oxidase
TMAO

19. TMAO
Patients with history of CV events had higher TMAO levels that those who did not.
Elevates TMAO levels had 3-4x higher mortality risk
Elevated TMAO levels had increased risk of heart failure
Ingestion of carnitene elevates TMAO and cholesterol

21. TMAO
highl
TMAO
low
TMAO
high

22. Carnitine Nutrient found in all meat products
Consumption causes a rise in TMAO
Meat eaters have higher TMAO than vegeterians
TMAO associated with raised CVD risk

23. TMAO TMAO = predictive risk factor for CVD
Associated with specific gut bacterial populations
Can be reduced by specific antiobiotics
Can be reduced by specific yogurt cultures
Can be reduced by specific foods (eg mediterranean)

24. Dietary components and CVD

25. DIETS: long term failures….
Seldom > 6 months in RT
Unpalatable: sugar and spice
Expensive
Unavailable
successful at weight loss but no survival benefit

27. the U curve………..
Low protein
Low carbs
Vegan
Banting
Atkins

28. The Mediteranian”lifestyle”
> 4 year compliance
Palatable(olive oil&nuts)
Obtainable
Weight loss
Survival benefit
=raised TMAO
Expensive

29. Can we expect to treat CVD by manipulating the gut microbiotica by diet or medication?
Stool analysis will once again become crucial.
Stool transplants?
…..and is it true then that the way to a man’s heart is indeed through his stomach?

30. THANKYOU!!